Thyroid Literature

Thyroid disease 136,053

Thyroid tumors 33,554

Thyroid Google search 36 million

Medline

• New Paper on Thyroid Disease – Every 3 Hours

• New Paper on Thyroid Cancer – Every 8 Hours

Thyroid Cancer Google search 21 million

The extirpation of

thyroid gland typifies

perhaps better than any

operation the supreme

triumph of the

surgeon’s art.

Halsted

Charles Proye-Lille, France

Postoperative Complications

• Postoperative complications

infrequent in experienced hands

• Early recognition and prompt initial

management crucial for successful

outcome

• Best prevented by meticulous

surgical technique

• When the surgeon talks about the surgical

series, divide it by 2 and then he talks about

the complications, multiply by 2.

• Only 20 % of the people will remember

20% of what you said 20 minutes after the

presentation.

• The surgeons are like politicians, they have

very short term memory.

Complications of Thyroidectomy

Wound hematoma – airway obstruction

Seroma – collection

Infection

Hypertrophic scar

Keloid

Recurrent laryngeal nerve injury – unilateral

Bilateral – rare

Hypoparathyroidism – temporary

Permanent

Recurrent hyperthyroidism

Hypothyroidism

Superior laryngeal nerve injury

Chyle leak

Horner’s syndrome – injury to sympathetic trunk – very rare

Complications in Thyroid Surgery

Increased incidence with

• Extent of disease (size)

• Extent of surgery

• Reoperative surgery

• Extrathyroid extension and malignancy

• Paratracheal dissection

• Neck dissection

• Substernal thyroid

• Reoperation for hematoma

• Less experienced surgeon

Bigger the operation, bigger the complications

Good judgement comes

from experience;

and experience comes

from bad judgement!

The risk of parathyroid injury is directly proportional to the extent of thyroidectomy and inversely proportional to the

surgeon’s experience.

Thyroid Surgery

Medical malpractice and the thyroid gland Lydiatt DD. Head Neck 25:429-431, 2003.

• Jury verdict reviews from 1987-2000 were obtained from a

computerized database

• 30 suits from 9 states occurred

• Plaintiffs were women in 80% of the cases, with a mean

age of 41

• 50% of pts (15 of 30) had a bad outcome, (9 of 30 dead, 4

of 30 with neurologic deficits, 1 blind & 1 alive w/ cancer)

• 30% alleged surgical complications, most RLN injury, and

75% of cancer pts alleged a delay, either through falsely

negative biopsies or no biopsy taken

• Respiratory events occurred in 43% and frequently

resulted in large awards

36 year old Head and Neck Surgeon undergoes total

thyroidectomy and central neck dissection. Status of the

parathyroid; unknown. Upper PTH, not seen. Lower PTH,

not sure due to CND.

• Questions:

– Drain

– Same day discharge

– Post-Op PTH assay

– When to check calcium level

– Calcium & Vit. D supplement at discharge

• Routinely

• Selectively

– How much calcium and Vit. D

– Iatrogenic hypercalcaemia

39 year old baseball coach undergoing

total thyroidectomy. Pre-Op vocal cord

evaluation, intra-op nerve monitor.

Post-op: pt is markedly hoarse with mild

stridor in the recovery room.

44 year old litigation attorney undergoes

uneventful total thyroidectomy.

6 hours after surgery: c/o throat

discomfort with mild neck swelling.

8 hours after surgery: Considerable

swelling, mild stridor

29 year old opera singer presents with 2.5 cm

Pap Ca. To be scheduled for thyroid surgery:

– Extent of surgery

– Pre-Op Evaluation

– Pre-Op discussion

– Intra-Op Decisions

– Sup laryngeal nerve

– Post-Op voice therapy

29 year old opera singer presents with 2.5 cm

Pap Ca. Scheduled for thyroid surgery:

– Intra-Op

• The nerve totally encased by tumor

• Shave

• Resect

• Reconstruct

Prospective Functional Voice

Assessment in Patients Undergoing

Thyroid Surgery

Stojadinovic/Shaha, et al.

Ann Surg 2002.

• To analyze voice before & after thyroid surgery

• Prospective study of 50 pts – functional voice testing

• Acoustic/aerodynamic/glottographic/videostroboscopic testing

• 30% pts reported early subjective voice changes

• 14% reported late subjective voice changes

• 84% had significant objective change in at least

one voice parameter

• 12% had significant alterations in more than 3 voice measures

• Early maximum phonational frequency range and

vocal jitter changes from baseline were significantly

associated with voice symptoms at 3 months

Post Thyroidectomy Central

Compartment Syndrome

• Submental anesthesia/paresthesia

• Vague voice changes

• Chronic throat discomfort

• Swallowing difficulties

• Feeling of choking

(Shaha)

Special Clinical Issues

• Superior laryngeal nerve

• Intraoperative nerve stimulation & monitoring

• Drains

• Management of substernal goiter

• Management of post-op hypocalcemia

• Tracheomalacia

SLN Injury

• Early vocal symptoms after thyroid surgery in 1/3 even if

no obvious evidence of RLN injury

• Half of these will have persistent symptoms 3 months

later

• Usual symptoms indicative of SLN injury lowered tone

vocal fatigue

difficulty in high-pitch phonation or

projection of voice

• Videostroboscopy and laryngeal electromyography may

be needed to confirm diagnosis of SLN palsy

• Speech pathology input for severe symptoms

RLN Injury

• Temporary nerve palsy may occur in up to 5% of

cases

• Permanent RLN injury and vocal cord paralysis

occurs in less than 2% to 3%

• Causes of transient nerve palsy include significant

manipulation & dissection along RLN

thermal injury

traction injury

RLN Injury

• Most permanent RLN injuries are due to transaction of

nerve during surgery

• May cause hoarseness, although voice can be normal

• Pre and Post op Larynx exam CRUCIAL

• Symptomatic patients may suffer from dysphagia and

aspiration

• Recovery of a temporarily paralyzed nerve that is

anatomically intact can take several months

• Consider vocal cord medialization if severe symptoms or

permanent paralysis

SB 35298453 (Dr. Shaha)

• 36 yo woman with recurrent thyroid cancer

• Jan 2011: presented with T4N1bM0 (stage I)

papillary thyroid carcinoma, classical type – Total thyroidectomy, central neck dissection, right MRND

– Right lobe primary tumor; 2.8cm, with extrathyroidal

extension into fibroadipose tissue

– 5 positive lymph nodes (levels 2, 6, & 7)

SB 35298453 (Dr. Shaha)

• Received 140 mCi RAI; post-treatment stimulated Tg 29.

• October 2011: presented with recurrent disease in right neck (levels 4 and 6), underwent revision neck dissection.

• Tg dropped to 15 (stable since, between 15 and 20).

SB 35298453 (Dr. Shaha)

• PET-CT July 2012:

– 2cm right retropharyngeal node (SUV 15)

– 1.5cm right level 2 node (SUV 3)

– 1.5cm left level 2 node (SUV 5)

• Cross-sectional imaging (for review)

SB 35298453 (Dr. Shaha)

50 year old female had total thyroidectomy in

Russia 18 months back. 3 positive nodes.

Received post-op RAI. Presented with

rising thyroglobulin and follow up

suggestive of local recurrence.

58 year old patient comes in with Pap Ca R

side with palpable R neck nodes

• 64 year old U.S. Senator had undergone a total

thyroidectomy for 2.6 cm papillary ca

6 positive nodes. Received 100 mCi. RAI 3 years back.

Presents with slight increase in thyroglobulin

U/S shows 6 mm paratracheal node

• Work up

• Treatment

Case

• 56 year old male noticed swelling in the left neck.

• FNA performed

• Surgical exploration showed multiple nodes in the neck.

• The disease in the thyroid was thought to be inoperable.

• Patient now presents 3 weeks after surgery

• Pathology – papillary carcinoma

Case #3

• 56 year old musician presents with repeated bouts of

hemoptysis.

• Chest x-ray shows thyroid mass with intratracheal

extension.

• FNA – Papillary carcinoma

•

Case #4

Treatment?

The staging system for papillary carcinoma of the

thyroid invading the trachea, based on the

histologic extent of invasion

• 23 year old medical student undergoes total thyroidectomy

and right modified neck dissection for papillary carcinoma

• 7 positive nodes

• Receives 150 mc RAI postop

• 1 years later thyroglobulin rises from 1.5 to 3.5.

• Ultrasound shows 5 mm right paratracheal node and 1 cm

right retrojugular node

Case #4a

Further treatment?

• 82 year old female presents with dysphagia and

shortness of breath

• Evaluation revealed submucosal mass in the

posterior pharyngeal area. Airway could not be

evaluated.

• Patient had total thyroidectomy and right MRD 19

years back with 2 courses of RAI

Case #5

• 39 year old marine biologist presents with right thyroid

mass – 4 cm, hard, fixed to the deeper structures.

No neck nodes.

• FNA – papillary ca

• Paralyzed right vocal cord

• Operative findings:

• Tumor involving the right RLN and constrictor muscles

• Right lobe removed with RLN

• Frozen section – poorly differentiated ca

• Left lobe – tumor involving posterior portion adherent to

the left RLN

Case

Case Presentation

• 31 year old actress with locally aggressive thyroid

ca – total thyroidectomy

• Tumor adherent to RLN

• Received 2 courses of RAI without uptake

• 2 years later paratracheal disease

Surgical excision, nerve ****** recovered 3 months

Case Presentation

• 2 years later – CXR

• PET also has 3 cm met tumor at level III

• PET positive – Chest and neck

Treatment for pulmonary metastasis and neck

Case Presentation

• 80 year old female was diagnosed with left thyroid

cancer – Papillary Ca 8 months back.

•Total thyroidectomy and post-op RT

•Presented now with dysphagia and left thyroid mass.

•FNA positive for papillary Ca

Case Presentation

• 34 year old female, very anxious

•Total thyroidectomy at age 18.

•Left modified neck dissection at age 28 with tumor stuck

to the nerve. Temporary paralysis post-op

•Now presents with mildly elevated TGB and U/S and CT

showing multifocal recurrent disease in thyroid bed and

central compartment of the neck